Basic Information
| Provider Information | |||||||||
| NPI: | 1831584473 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CISNEROS | ||||||||
| FirstName: | MARIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | SSB-6 | ||||||||
| Address2: | 400 E 3RD ST | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 653 W 8TH ST # L18 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443907 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 70064 | MN | Y | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | OS15211 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.